Development of an Integrated Urgent Response, Short Term Rehabilitation and Reablement Delivery Model Overview Health and Wellbeing Board 2 nd May 2017 1
Purpose • To outline the work taking place between ASC and GSTT to integrate GSTT adult community services with Southwark Adult Social Care in 2017/2018 to simplify and improve access to home-based rehabilitation, social care support and reablement • This integration aims to: – Avoid admission to hospital, care homes and A&E attendance – Support people to live at home, regain independence, maximise choice and control and live safe and well in their communities – Improve experience & outcomes – personal, staff & system • Recommendations: – Note work taking place and the phased implementation of changes to ensure a smooth transition whilst maintaining current service delivery and performance ( section 8) – Note stakeholder engagement activities taken place so far and further plans to engage stakeholders in development of the service & embed the changes (section 11) – Feedback any comments to further shape & inform changes 2
Context • Provider driven - Initiative to further integrate, simplify & improve the pathway - work commenced May 2015 • Approach – Building a system leadership coalition, “bottom up” design - co-productive working with commissioners from January 2016 Approved – 5th & 6 th April 2017 by Council’s Children & Adults • Board and GSTT Trust Management Executive 3
Summary Changes: • Service operates as a single integrated pathway in North and South Southwark, with simple access to urgent services (within 2 hours) and short term access (within 2 days) • Will keep people at home with intense rehabilitative support provided by both GSTT and Southwark Adult Social Care services and help people go home from hospital faster through services working together better • Managerial, workflow and service integration will be phased over a 12-18 month period, with gateway reviews to progress planned organisational and pathway changes • Complex change requires co-location of staff, new line management and team structures, realignment of professional supervision, and strong joint- working arrangements for managing outsourced domiciliary/reablement contract staff. 4
Case for change • National & local drivers : Care Act, Better Care Fund, NHS Five Year Forward View, Southwark’s Five Year Forward View, Sustainability & Transformation Plan, ASC Vision & Priorities, GSTT’s Strategic Plan, A&E Improvement Plan • Better management of demand: Reduce people entering A&E, demand on acute services, number of delayed discharges and long term care packages • Alignment / become part of LCNs: Focus on populations, and local provision in networks • Creating a multi-professional workforce: Provide person-centred, joined up care which will reduce duplication & hand offs • Improving productivity: Address skills gaps and realise efficiencies • Outcome based commissioning and alliance contracting: Opportunity to move towards a quality driven and more cost efficient model • Delivering commissioning intentions: Contribute towards; Rehab Pathway; Dementia Pathway; Care at Home & Reablement procurement; Falls prevention 5
Current population cohorts • Predominantly older adults with a physical disability/ frailty • Recovering from a short term illness or impairment or crisis • Housebound • Typically post acute admission /avoiding acute admission • Multiple pathologies/ multi-factorial • Needing intensive (once a day or more) interventions to improve functional independence • Health and/or social care professional skills required Desired Outcomes: • Improved independence and self care, prevention of falls, resilience for further illness/episodes, re-engaging with community • Focus on the following needs – mobility, personal care, toileting, meal preparation, home environment, family and carers 6
Current service configuration in the pathway Short Term Rehab & Reablement Urgent Response Supported @home Enhanced Rapid Response Discharge Team & Double Handed Unified Point of Service ASC Reablement Access Service Neuro Rehab Enhanced Transition Pal@home ASC – Urgent Team – part of Early Supported Response Function Neuro Rehab Discharge for Stroke Service Clients ‐ 24@home part of Neuro Rehab Service Community Rehab & Falls Team Neuro Long Term Conditions Team – Key – delivered part of Neuro by: Rehab Service Intermediate Care GSTT Beds GSTT ASC ASC 7
Future configuration: Access, Urgent Response, Short Term Rehabilitation & Reablement ALL Referral routes: ASC screening, GP, Hospital Discharge Teams, Community Nurse, SW, support worker, LAS etc URGENT RESPONSE UNIFIED POINT OF ACCESS Health and Social Care Created by building on current ERR and @home Unified Point of Access URGENT RESPONSE COMPONENT & SHORT TERM REHAB AND REABLEMENT COMPONENT @home Community Multi ‐ disciplinary response Pal @home Rehab & Falls 24@home Created by bringing together: Triage Enhanced Rapid Response • Provision of • ASC social work Intensive medical / • Supported Discharge Team (incorporates Double Handed Service) nursing support • Reablement Reablement and Rehabilitation Workers Key – delivered by: Neuro Rehab Service • Neuro Rehab Enhanced Transition Team GSTT GSTT • Early Supported Discharge for Stroke Clients ASC • Neuro Long Term Conditions 8
Workflow structure phase 1&2 – Formal Shared leadership and management with MDT ‘pods’, LCN contact/liaison, 2 locations, joined up urgent/non urgent workflows T R I A G Urgent Urgent E GSTT Rehab workflow support T & workers R I A A L G L E O Non-urgent Reablement C workflow contract Short term and rehab and A support workers reablement T I O N Admin and business support 9 9
Workflow structure phase 3 – One leadership and management structure, organised by LCN, all workflows joined up, support staff work throughout pathway T R I A G North Service Urgent E workflow & GSTT Reablement Rehab A contract support L support workers L workers O Non-urgent C workflow South Service A T I O N Admin and business support 10 10
Phases: April 17 to April 18 • Establish shared governance, benefits and outcome arrangements • Formalise joint management from 'As is' roles, develop options and consultation for disaggregation of GST Lambeth and Southwark management structure Phase 1 • Review Reablement and urgent social care workflow demand (numbers and skills/staffing needed) April – Sept17 • Identify possible financial and contractual, premises and IT changes required • Review learning- from phase 1, define accountabilities and review governance, benefits and outcome arrangements • Staff consultation for GST leadership and management roles. New structure agreed • Agree Reablement workflow requirements and implement change to practice and define revised Phase 2 skill mix • Agree Reablement contract and GSTT RSW staff transition plan to both work across whole pathway September 17 – March 18 • Further clarification of any financial and contractual changes : Progress Premises and IT changes • New structure in place with Lambeth Southwark split and/or agreement on what is shared • Clear final accountability and responsibility structure and shared governance, benefits and outcomes arrangements in place • Final staffing skill mix implemented with GST and Reablement contract staff working across whole Phase 3 pathway April 18 onwards • Aligned and integrated practice standards and protocols in place for all workforce • Financial arrangements agreed for 18-19: Changes to premises and IT implemented 11
Why are we recommending this approach? • Can start the arrangements now, establish the service & resources, maximising use of vacant posts where possible • Allows current management experience to be utilised for transition and start up • Allows 3 to 6 months for GSTT to disaggregate management posts and for ASC and GSTT to consider equity in grading for management posts and clarify accountabilities –e.g. with CQC • Can establish one leadership & management team made up of Service, Team and Deputy Leads / Managers • Learn from doing, build confidence and trust, make sure we move to robust arrangements underpinned by a working culture that will sustain integrated working in practice • Continue to work on understanding/agreeing needs of the service users in the changed workflow, staffing and skills mix, accommodation and IT access • Continue to engage stakeholders in the development of the model • When confident have the critical mass - teams can be realigned to North and South LCNs 12
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